Insulin treatment - Dr.Kania

Question 1

Route of administration for insulin fastest absorption to slowest

Answer 1

IV,IM,SUBQ

Question 2

Site of injection for insulin

Answer 2

Stomach (fastest), Buttocks and thigh (slowest)

Question 3

Factors that affect insulin absorption

Answer 3

Temperature
- heat increases absorption and action
(dont rub on site of injection after injection)
Exercise/massage
-Increased absorption and action
Effect may depend on injection site

Question 4

Stability of insulin vials

Answer 4

Stable at room temperature for 28 days
Refrigerate un-open vials but do not freeze

Question 5

Complications of insulin therapy
- hypoglycemia

Answer 5

1. Hypoglycemia
   - This can be causes by too high of an insulin dose, too little food intake, excess workouts, or excess alcohol consumption.
   - signs include: altered mental state, shaking, anxiety, dizziness, hunger, confusion, blurred vision
   - 3 levels of hyperglycemia
   level 1 = Glucose <70 mg/dL
   level 2 = <54 mg/dL
   level 3 = severe event with altered mental status

Question 6

Treatment for Hypoglycemia

Answer 6

RULE OF 15
- start with 15mg of fast acting carbohydrates unless BS <50 (then do 30)
Wait 15 minutes and check BS again if its not >79 repeat another 15mg of fast acting carbs

Fast acting carbs include
- 4 oz of juice, 6 oz of soda, 5-6 lifesavers, 1 T of honey

Follow with complex carbohydrate (piece of toast with PB)
Eat Meal if it is within the hour
- eat 30mg of carb snack if meal is > one hour away

Question 7

Complications of insulin therapy
weight gain

Answer 7

When patients first start insulin therapy they take it as an excuse to eat more food so make sure to counsel on that

Question 8

Complications of insulin therapy
Lipohypertrophy

Answer 8

This happens when a patient repeats injections on the same site for a long period of time

Question 9

Complications of insulin therapy
Lipoatrophy

Answer 9

antibodies or allergic reaction causes distruction of fat and will cause these dented in parts of the leng

Question 10

Advantages and disadvantages to Ultra short acting insulin (Glulisine, Lispro or Aspart Insulin)

Answer 10

Advantages
- Decrease the risk of hyoglycemia after eating
- fewer instances of hyoglycemia and less nocturnal hypoglycemia
- greater flexibility with dosing
Disadvantages
- Greater risk of hypoglycemia if you dont eat within 15 minutes of taking shot
- Patient has to take a long acting insulin as well which means more shots given
- If you are using a mix with short acting insulin you must give the shot Immediately after mixing

Question 11

Advantages and disadvantages of Long-acting insulin (Glargine, detemir, or degludec)

Answer 11

Advantages
- these will provide 24 hour coverage of insulin for the patient with less risk of hypoglycemia because they do not have a sharp peak of insulin release
- They can be helpful with nocturnal hypoglycemia due to NPH because NPH has a peak right when injected

Disadvantages
- these cannot be mixed with any other insulins

Question 12

Changing insulin therapy from U-100

Answer 12

If patient is taking daily NPH then ratio for long acting insulins are 1:1 (Dose is the same)

If patient is takinf NPH BID (TWICE) you have to decrease the dose of glargine, detemir, degludec by 20%

Question 13

Changing U-100 to concentrated insulin

Answer 13

If patient was on BID NPH and not starting U-300 decrease dose by 20%

1:1 conversion between basal insulin and U-200 insulin (tresiba)

1:1 conversion between lispro U-100 to U-200

Question 14

conversation for U-100 basal-bolus to U-500

Answer 14

Calculate patients total daily dose of insulin
A1C >8% 1:1
A1c< or equal to 8% use 20% dosage reduction

Question 15

Dose for type 1 patients

Answer 15

Average daily dose 0.5-0.6U/kg/day

For new diagnosis usually start with 0.4 because type one patients will usually have a honeymoon phase where when they take insulin their pancreases remembers it can make some and releases insulin.

Type one patients should usually test BS 4 times a day before meals and occationally at bed time (3am) to assess insulin dosages

Question 16

Dosing for type 2 patients

Answer 16

Usually long acting insulin

Starting dose
0.1-0.2 units/kg/day or 10 units/day
A1C >8% start with 0.3-0.4
A1c < 8% Start with 0.1-0.2
(10-15 units)

Dose should be increased by 2 doses every 3 days to reach FBG of 80-130

Question 17

Insulin to carb ratio

Answer 17

1 unit of insulin = 10-15 grams of carbohydrates

Question 18

RULE of 500

Answer 18

take 500 divided by daily insulin dose and this will equal the number of gm of carbs for 1 unit of insulin
1 carb = 15grams

Question 19

Correction factor ISF RULE OF 1800

Answer 19

1800 divided by total daily dose of insulin = number of mg/dL blood glucose will drop for every 1 unit of insulin

EXAMPLE
patients TDD: 90 units
1800 divided by 90 = 20
this means 1 unit of insulin will drop blood sugar levels by 20 mg/dL

Question 20

Somogyi Effect

Answer 20

nocturnal hypoglycemia with rebound hyperglycemia
Check BS at 3 am and ask about signs and symptoms
sings include : sweating and scary dreams
Move NPH from dinner to bedtime or decrease long acting dose at bedtime

Question 21

What to do if you are sick?

Answer 21

Still take insulin and monitor BS levels every 4 hours
Make sure to stay super hydrated - drink twelve 8 oz glasses a day

Question 22

How to know when its time to change to concentrated forms

Answer 22

Concentrated forms where created to increase absorption at higher doses and lower risk of hypoglycemia, fewer infections, less pain (Less shots)
Change to concentrated forms when patient is at a extremely high dose because with this high dose its unpredictable how much of it is actually being absorbed

Consider patient for concentrated form when their TDD is 200-300 units a day